By Jacob S. Hacker
Sunday, March 23, 2008
"Socialized medicine" is the bogeyman that just won't die. The epithet has been hurled at every national health plan since the New Deal -- even Medicare, which critics warned would strip Americans of their freedom.
And now it's back. Republicans from President Bush on down have invoked the specter of socialism in denouncing Democrats' attempts to expand publicly funded health insurance for children. Erstwhile GOP presidential contenders Rudy Giuliani and Mitt Romney lambasted the health plans of the leading Democratic candidates for mimicking "the socialist solution they have in Europe" (Giuliani) and trying to impose "a European-style socialized medicine plan" (Romney). The presumptive Republican nominee, Sen. John McCain, hasn't used the S-word yet, but after sewing up the nomination in early March, he criticized Democrats for intending "to return to the failed, big-government mandates of the '60s and '70s to address problems such as the lack of health-care insurance for some Americans."
Never mind that nobody is proposing to turn doctors into public employees and hospitals into government institutions -- the literal meaning of socialized medicine. The slogan gets its punch because it invokes a visceral public fear: that government involvement will drive up costs and drive down quality, wrecking the economy and damaging your health. Expanding government's role, the naysayers insist, will destroy what McCain calls "the world's best medical care."
But the critics have it backward. The best American medical care is indeed extremely good, but much of our system falls short -- especially when you consider how costly it is, how heavy a burden it places on employers and families, and how many it excludes. And far from being a threat, getting the government more involved in health care would actually reduce costs, improve quality and bolster the U.S. economy -- which helps explain why public insurance is the secret weapon in both of the leading Democratic candidates' plans. If socialized medicine means doing what our public-insurance programs and other nations' health systems do to control costs, expand coverage and improve the quality of care, it's high time for a little socialization.
To see the advantages of public insurance, just look at the program that once prompted the fiercest charges of socialized medicine, Medicare. Since the introduction of cost controls in the 1980s, Medicare's expenditures have grown at a substantially slower rate than spending on private insurance, according to a recent analysis by the health-care experts Cristina Boccuti and Marilyn Moon. And despite Medicare's comparative frugality, the program's beneficiaries express greater happiness with their coverage than do privately insured patients in surveys of consumer satisfaction.
Other industrialized nations have also seen the benefits of public insurance. Around the same time that Medicare cracked down on payments, most rich nations began more actively negotiating with doctors and hospitals to keep prices from rising through the roof. Lo and behold, medical inflation in most of the industrialized world has slowed dramatically, as the health policy specialist Chapin White has shown. But without such coordinated restraint, U.S. spending on health care has continued to rise rapidly -- a far cry from the 1970s, when our health-care spending per person was comparable to that of other rich nations and growing at about the same rate.
You'd think that those lower costs abroad would mean worse care. (You'd certainly think that if you listened to GOP candidates sneering at the British, French or Canadian systems.) But the closer one looks, the more unexceptional -- and often downright mediocre -- U.S. care looks.
Consider some basic measures of health-care infrastructure, such as those surveyed in a series of analyses by a team led by Gerard Anderson of Johns Hopkins University. The United States has fewer doctors, hospital beds and nurses per person than the norm among rich nations: 2.4 doctors per 1,000 people in 2004, for example, compared with 3.4 in France, which spends just over half what we do per person. Moreover, Americans visit doctors and hospitals less frequently and have shorter hospital stays than citizens in other affluent countries: The oft-maligned French see their doctors enough to rack up an average of 6.4 visits per person in 2004, but the American number was just under four visits. And we lag far behind other rich nations in the use of information technology, such as electronic prescription systems, to improve quality and lower costs.
Indeed, by some measures, U.S. health care looks downright lousy. A six-country study by researchers at the Commonwealth Fund, a health-care think tank with a generally liberal bent, concludes that the United States "scores particularly poorly on its ability to promote healthy lives, and on the provision of care that is safe and coordinated." Meanwhile, a recent analysis of 19 rich nations by Ellen Nolte and C. Martin McKee of the London School of Hygiene and Tropical Medicine found that the United States has the highest rate of "amenable mortality" before age 75 (the odd term of art for deaths that could have been prevented with timely care) -- and that we're falling farther behind.
Yes, the United States performs well in some areas of high-tech care and preventive screening. And, yes, waiting lists for non-emergency procedures do crop up in other rich nations. But even countries without such lists spend vastly less than we do. (And if you find an American who's never had to wait for care, get me their doctor's number.) Given how much we shell out, what's really striking is how poor our care frequently is. Back in the 1940s and '50s, corporate America promoted private benefits as an alternative to government insurance on the grounds that they offered better value. Now bosses -- and the rest of us -- are living with a raw deal that U.S. business would never stand for in other areas of today's competitive economy.
It's time, in other words, to embrace a government role in health care, rather than run from it.
Americans seem ready. They increasingly back government action to expand health coverage -- by more than 2-to-1 margins in recent polls. And the old bugaboos of government control don't seem to scare them as they once did. In fact, in a survey last month by the Harvard School of Public Health, 60 percent called Medicare socialized medicine -- a perception that hasn't dented the allure of this wildly popular program. Of the 82 percent who professed to know what the loaded phrase meant, more people thought that this long-demonized prospect would be good for the nation than thought that it would be bad.
Corporate America, too, seems more ambivalent than ever about the Faustian bargain it made to kill national health insurance in the 1940s. The nation's automakers, for instance, once stood on the front lines in the battle against socialized medicine. Now they spend more on health care than steel. No wonder they're talking about "national solutions" to reduce the medical burden.
The political landscape is shifting, too. Leading Democrats now seem far more willing to discuss public insurance than was President Clinton in the early 1990s (who backed a market-based plan and saw it caricatured as a big-government monstrosity anyway). Both Sens. Barack Obama and Hillary Rodham Clinton are arguing that workers whose employers don't provide coverage should be able to buy into a public program modeled after Medicare. And they've emphasized that Washington will need to take the lead in developing the technology, information and standards necessary to improve the quality of care.
That's wise, because the only proven way to provide good affordable care to all Americans over the long run is to expand public insurance.
Don't take my word for it. The Lewin Group, a well-respected health-care consulting firm, recently estimated the potential impact of a health plan I've developed with the support of the Economic Policy Institute. The proposal -- which resembles the plans of the leading Democrats, whom I've advised -- requires employers either to cover their workers or to contribute to the cost of their workers' coverage. Workers whose employers make the contribution will be enrolled in a public plan modeled after Medicare. Like those covered by Medicare, they will have the option of purchasing regulated private insurance instead. According to the estimates, this proposal would cover all but a tiny sliver of the non-elderly population -- about half through the new federal system and half through employers. Yet it would actually reduce national health spending, cost the federal government an eminently reasonable $50 billion a year (about what the Medicare drug benefit costs) and save states and employers big money.
How is it possible to cover everyone without driving up costs? The one-word answer is "government" -- specifically, government's ability to lower service prices, streamline administration and get a better deal on drugs, thus reducing medical inflation over time. And these are only the direct savings. Reducing the burden of health care on employers will allow them to compete more effectively (and on a level playing field) with foreign producers. Just as important, making coverage affordable for everyone will allow people to change jobs or start their own businesses without the fear of catastrophic costs or the hassle, expense and inadequacy of individually purchased coverage.
Maybe socialized medicine doesn't sound so bad after all.
Jacob S. Hacker, a professor of political science at Yale and a fellow at the New America Foundation, is the author of "The Great Risk Shift: The New Economic Insecurity and the Decline of the American Dream."